Date of Request
Visit Number
Chart #:
BASSETT HEALTHCARE NETWORK
REFERENCE LAB
LAB TEST REQUEST FORM #2
*0102*
__
Location:
#0102(f\lab\.doc)
1/06,7/06,10/4/06,1/07,4/07,8/1/07,1/31/08,7/1/08,8/25/08,10/6/08,4/6/09,
7/6/09,10/5/09,1/4/10,3/29/10,7/19/10,10/4/10,1/3/11,4/4/11,10/3/11,
1/16/12, 4/1/13, 4/7/14, 7/7/14, 10/6/14
Ordering Provider: ________
Patient Name
Attending Provider: ________
Date of Birth
Please circle requests below.
TIME:
SPECIMEN
DATE:
COLLECTED BY:
ICD-9 Code
or
Descriptive Diagnosis:
PROVIDERS: Compliance is mandatory and regulated. For the laboratory to bill properly and receive payment, you must provide the specific ICD-9 codes for each outpatient test ordered. Additionally, only tests that are medically
necessary for the indicated diagnosis or treatment should be ordered, with supporting documentation in the medical record. For tests included in each panel and reflexive testing, please refer to the back of the requisition form. Under
current Medicare regulations, when certain laboratory tests (indicated by an *) are ordered, and the diagnosis is not listed in the Local Coverage Determination or National Coverage Determination for that test, payment may be denied. In
these cases Medicare requires an Advance Beneficiary Notice (waiver of liability) be signed to allow the hospital to bill the patient. The ABN box on the requisition MUST be checked when an ABN is obtained.
Patient has signed ABN Waiver (ABN) Patient refused to sign ABN Waiver (ABNR)
ABN not required
♠ ALSO NEEDS MAYO COAGULATION PATIENT INFORMATION FORM (MAYO #T675) – AVAILABLE FOR PRINT ON BASSETT LAB MANUAL WEB PAGE AT EACH TEST
♦ PLACE ON ICE IMMEDIATELY ♣ PRE-CHILLED LAVENDER TUBE
♥ KEEP AT 37 DEGREES C
SERUM/PLASMA
Test Name
Code
Code
IGES
IgE
ACH
Acetylcholine Receptor Binding Antibody
IGG1
IgG Subclasses
IGF-1 (Insulin Like Growth Factor-1)
♣♦ACTH
Test Name
Adrenocorticotropic Hormone (ACTH)
SOMC
ALDO
Aldolase
IMMFLC
Immunoglobulin Free Light Chains
ASNSR
Aldosterone
INSF
Insulin, Free
API
Alkaline Phosphatase, Total and Isoenzymes
INSU
Insulin, Total
A1A
Alpha-1 Antitrypsin
A1AP
Alpha-1 Antitrypsin Phenotype & Total
LUPPR
LYMBR
Lupus Anticoagulant Comprehensive Eval
Lyme Disease Antibody Western Blot
AFP
Alpha Fetoprotein (AFP) – Maternal Only
TSUB
AFPN
Alpha Fetoprotein (AFP) – Tumor Marker
A1CE
Angiotensin Converting Enzyme (ACE)
AT3AG
AT3
• PROTECT FROM LIGHT
Code
►NEED MAYO DNA CONSENT FORM
Test Name
OTHER BODY FLUIDS
BPPCR Bordetella PCR (Nasopharyngeal)
24 HOUR URINE (Includes 24 hr container)
Code
Test Name
TOTAL VOLUME: (24UR)________________
*
5HQT
5HIAA (5Hydroxyindolacetic Acid)
CFCU
Catecholamines, Fractionated
CD4 T-Cell Count, NY (Lymphocyte Subset Profile 4) *
FUC
Cortisol, Free
MNTPF
Metanephrines, Fractionated –Plasma
MNTU
Metanephrines, Fractionated
MGAP
Methylmalonic Acid, Quant.
NTX
N-Telopeptide (Collagen Cross-Linked)
Anti-Thrombin III, Antigen
AMCD
Mitochondrial Antibody
KSDP
Supersaturation Profile
Anti-Thrombin III, Function (Activity)
MVSA
Mumps Virus Antibody, IgG
VMAU
VMA
ASO
ASO Titer (Anti-Streptolysin O)
MUMP
Mumps Virus Ab, IgG and IgM
BCPCR
BCR/ABL, p210, Quant, Monitor to Mayo
MPNA
Mycoplasma Pneumoniae Antibody (IgG/IgM)
RANDOM URINE
B2MG
Beta-2 Microglobulin
NABA
Neutrophil Cytoplasmic Antibody Profile
HISTU
Histoplasma Antigen
C153
CA 15-3*
17HY
17-OH Hydroxypregnenolone
MUQT
Myoglobin
C199
CA 19-9*
17HP
17-OH Hydroxyprogesterone
NCOT
Nicotine and Metabolites
CA27
CA 27.29*
PTHRR
Parathyroid Hormone-Related Peptide (PTHrP)
CLCA
Stone Analysis
CCTNR
Calcitonin
PRVO
Parvovirus B-19 Antibody IgG/IgM
ACDL
Cardiolipin Antibodies (IgG, IgM, IgA)
ACGM
Phospholip Ab (Cardiolipin) IgM/IgG
STOOL
CTFP
Catecholamines, Fractionated
PBAG
Platelet Antibody (IgG) Direct
HPAG
Helicobacter pylori Ag
CTSC
Cat Scratch AB IgG & IgM
PLTT
Platelet Antibody (IgG) Indirect
LPTF
Lipids, Quantitative (Fecal Fat),(random or timed)
CENTR
Centromere Antibody
PTCA
Protein C Activity
MISCELLANEOUS DRUGS
CERU
Ceruloplasmin
PRTC
Protein C Antigen
ATRP
Amitryptline & Nortriptyline
CGRAR
Chromogranin A
PTSA
Protein S Activity
DSUN
CMAG
CMM
CMV Antibody (IgG)
CMV Antibody (IgM)
PRS
Protein S Antigen
Drug Screen, 10 Drug, with Confirmation, THC cutoff
50ng/ml (Urine)
CH50
Complement, Total CH50
CPEP
C-Peptide
Cryoglobulin & Cryofibrinogen Panel (3 Reds & 1 Lav)3
♥CFBG
CCPG
CYCNS
ANCA
DHSP
DSDN
SM
RNP
EBVC
EBAGB
Cyclic Citrullinated Peptide Ab
Cyclosporin to Mayo
Cytoplasmic Neutrophilic Ab
DHEA-sulfate
DNA Auto Antibodies Double Stranded (Farr Endpoint)
ENA Ab.(Autoantibodies to SM)
ENA Ab.(Autoantibodies to U1RNP)
Epstein-Barr Virus Antibody Profile
Epstein-Barr Virus PCR, Quant, B
Proteinase 3 Antibodies, IgG (PR3)
LMTG
Lamotrigine (Lamictal)
Prothrombin Gene Analysis
LVTA
Levetiracetam
QFEV
Q Fever Ab, IgG and IgM
MTXTR
Methotrexate, Routine
QTBG
Quantiferon Gold
MTXT
Methotrexate, STAT to Albany Medical Center
Renin, Activity
OXCZP
Oxcarbazepine Metabolite (MHC) (Trileptal)
PT3AB
♠►PTGA
♣♦RENPR
ROT
Rotavirus Antigen, Feces
ASCL
Scleroderma – 70 Antibody (SCL-70)
SRTN
Serotonin
ASMA
Smooth Muscle Antibody
SJO1
SS-A (Sjogren’s Antibody)
SJOG
SS-A and SS-B Sjogren’s Antibodies, IgG
SJO2
SS-B (Sjogren’s Antibody)
Syphilis Antibody by TP-PA, Serum
T3 (Triiodothyronine), Free
ERYP
Erythropoietin
TPPA
ESTI
Estriol (E3), Unconjugated, Serum
T3F
ESTGN
Estrogens, E1 + E2, Fractionated
T3UP
T3 Uptake (Triiodothyronine)
ENAP
Extractable Nuclear Antigen Evaluation, Ab to
T4T
T4 Total (Thyroxine)
FPHTN
Phenytoin, Free
PRMI
Primidone & Phenobarbital
SRLM
Sirolimus (Rapamycin) to Mayo
Last dose: date_____, time_____,mg_____
TACR
Tacrolimus (FK506, Prograf) to Mayo
Last dose: date_____, time_____,mg_____
TOPIR
Topiramate (Topramax)
CELIAC DISEASE TESTING
AEMA
Endomysial Antibody, IgA
RCMISCR
Inflammatory Bowel Disease Panel
AGLAA
Gliadin Antibody IgA
AGLAG
Gliadin Antibody IgG
AGLP
Gliadin Antibody IgA and IgG
Factor V (Leiden Mutation)
TESTF
Testosterone Free (includes Total Test)1
FCT5R
Factor V Assay
THYGR
Thyroglobulin Antibody
FCT7R
Factor VII Assay
TTPAR
Thyroglobulin Ab & Thyroid Peroxidase Ab
G6PD
GAST
G6PD, RBC
Gastrin
ATGBR
Thyroglobulin & Anti-Thyroglobulin Ab
ATMA
Thyroid Peroxidase Ab
AGBM
Glomerular Basement Membrane IgG Ab
TXABT
Toxoplasma Antibodies (IgG, IgM)
GADAB
Glutamic Acid Decarboxylase (GAD65) Antibody
TRYPR
Tryptase
GH
Growth Hormone (hGH)
TSIGR
TSI (Thyroid Stimulating Immunoglobulin)
AEMAR
Tissue Transglutaminase Antibody, IgA
HPTG
Haptoglobin
VTB1
Vitamin B1 (Thiamin)
HCDNA
Hemochromatosis HFE Gene Analysis
D125
Vitamin D, 1,25-Dihydroxy
TTGG
ATGAG
Tissue Transglutaminase Antibody, IgG
Tissue Transglutaminase Antibody, IgA
HGBER
Hemoglobin Electrophoresis
VD25F
Vitamin D, 25 Hydroxy*
XAL
Heparin Anti-Xa
VWBAR
von Willebrand Factor Ag
♠►F5L
Heparin-PF4 Ab (HIT)
Hepatitis C Virus (HCV) FibroSURE *
Herpes Simplex Antibodies Type 1-2, IgG
Herpes Simplex AB Type 1/2, IgG & IgM Total
HSVABM
Herpes Simplex Antibody, IgM
► HB27 HLA -B27 (Ethnic Origin _____________)
♦HCS
Homocysteine, Plasma
♦RCMISCR Homocysteine, Serum
VIRAL TESTING
PPDCTX
HLA Typing, Celiac Disease
Prometheus Thiopurine Metabolites
►TPMTENZ
TPMT (Thiopurine s- methyltransferase
►RCMISCT
TPMT (Thiopurine Methyltransferase
Enzyme to Prometheus)
Genotyping to Prometheus)
2
CULTURE
VIRI
Non-Respiratory
RSVCX Respiratory
DETECTION BY PCR
CMVD
Cytomegalovirus [CMV] (blood)
RCMISC (-R,-F,-T) Cytomegalovirus (CMV) PCR (other sources)
HPVPC Herpes Simplex Virus (HSV) (genital/dermal)
HSVZPCR HSV and VZV DNA (dermal)
and IgG
OTHER TESTING (Test Name)
________________________________________
________________________________________
Provider’s Signature: ________________
Signed Date and Time: ________________
Received by: ________________________
REQUISITIONS Lab
HAT
FBSR
HSA
HSVAB
HLACD
1.
TESTF includes both a Total Testosterone and a Free Testosterone by equilibrium dialysis.
2. The Mayo laboratories have found nucleic acid amplification to be more sensitive and rapid than shell vial assay for the
detection of CMV, HSV and VZV from certain specimen sources. Upon receipt of requests for viral cultures on the
following specimen types, Mayo will call MIBH to cancel the viral culture and order the corresponding test as noted
below.
3.
•
For requests for CMV, DNA Detection and Quantification on blood, see:
A. CMVQU “Cytomegalovirus DNA Detection and Quantification, Plasma
•
For requests for CMV, Molecular Detection on fluid, bone marrow, urine specimens, etc., see:
A. LCMV "Cytomegalovirus [CMV] Molecular Detection, PCR."
•
For requests for HSV/Varicella-Zoster Virus on genital and dermal specimens, see:
A. LHSV "Herpes Simplex Virus (HSV), Molecular Detection, PCR"
B. LVZV "Varicella-Zoster Virus (VZV) by Rapid PCR"
C. LHSVZ "Herpes Simplex Virus (HSV) and Varicella-Zoster Virus (VZV) Molecular Detection, PCR”
When a Cryoglobulin, Plasma and Serum (CFBG) is ordered both Cryoglobulin and Cryofibrinogen will be performed.
Both plasma and serum need to be sent (lavender top and two large red tops) need to be drawn and kept @ 370 C while
clotting.